Prevention of Future Deaths reports · 2018

Herbert Francis

Regulation 28 report to prevent future deaths, reference 2018-0242, written 26 Jul 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report26 Jul 2018
Reference2018-0242
DeceasedHerbert Francis
CoronerJonathan Layton
Coroner areaCarmarthenshire and Pembrokeshire
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS  

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

1 

CORONER 

 AM Cabinet Secretary for Economy and Transport

I am Jonathan Mark Layton senior coroner, for the coroner area of Carmarthenshire and 
Pembrokeshire. 

2 

CORONER’S LEGAL POWERS 

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 

3 

INVESTIGATION and INQUEST 

On 9th January 2018 I commenced an investigation into the death of Herbert John 
Bernard Francis. The investigation concluded at the end of the inquest on 26th July 
2018. The conclusion of the inquest was road traffic collision.  The medical cause of 
death was Ia multiple traumatic injuries Ib road traffic accident. 

4 

CIRCUMSTANCES OF THE DEATH 

(1)  Herbert John Bernard Francis was driving his Skoda motor car along the B4313 

towards the A40 road at Redstone Cross. 

(2)  Mr Francis failed to stop at the junction with the A40 and collided with an 

articulated heavy goods vehicle being driven along the A40. 

(3)  As a result of injuries sustained in the collision Mr Francis died at the scene. 
(4)  At the inquest evidence was received from a collision investigation officer, 

namely
rectified in the interests of public safety.

, who identified road defects that he believed should be 

5 

CORONER’S CONCERNS 

During the course of the inquest the evidence revealed matters giving rise to concern. In 
my opinion there is a risk that future deaths will occur unless action is taken. In the 
circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows.  –  

(1)   The approach to the main A40 from Redstone Road could be further enhanced 

with the introduction of road markings and early warning signs.  That 
consideration should be given to the re-positioning of the national speed limit 
signs from their current location to closer to the mouth of the junction. 
(2)  That both filter lanes on the A40 at this location should be made longer and 

wider. 

(3)  That consideration should be given to lowering the speed limit along this stretch 
of road, or by placing advisory speed limit signs at the location to warn motorists 
of the upcoming bend and junction. 

(4)  That filter lanes should also be introduced on the A40 for vehicles heading 

1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 westbound and intending to turn left onto Redstone Road.

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you have the 
power to take such action.  

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by the 23rd September 2018. I, the coroner, may extend the period. 

Your response must contain details of action taken or proposed to be taken, setting out 
the timetable for action. Otherwise you must explain why no action is proposed. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following Interested 
Person: 

 2 Cwm Aur Llanilar Aberystwyth Ceredigion SY23 4NT 

I am also under a duty to send the Chief Coroner a copy of your response.  

The Chief Coroner may publish either or both in a complete or redacted or summary 
form. He may send a copy of this report to any person who he believes may find it useful 
or of interest. You may make representations to me, the coroner, at the time of your 
response, about the release or the publication of your response by the Chief Coroner. 

9 

26th July 2018                                             Signed: J M Layton 

2

Responses

1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Welsh Government (PDF)
Ken Skates AC/AM 
Ysgrifennydd y Cabinet dros yr Economi a Thrafnidiaeth 
Cabinet Secretary for Economy and Transport 

Ein cyf/Our ref KS/02354/18 

Mark Layton 
H M Senior Coroner  
Carmarthenshire and Pembrokeshire 

hmcpembs@btconnect.com 

15 August 2018  

Dear Mark, 

Thank you for your email of 26 July enclosing your report following the inquest into the  
death of Mr Herbert John Bernard Francis.  

I acknowledge the very sad circumstances surrounding the death of Mr Francis and accept 
that in your opinion there is a risk of future deaths at this location unless appropriate action 
is taken. 

My  officials  are  currently  in  the  process  of  carrying  out  a  three  year  speed  limit  review 
looking at road safety issues at over 600 sites on all trunk roads in Wales.  I have asked my 
officials  to  ensure  the  concerns  and  recommendations  raised  in  the  report  are  considered 
as  a  priority  as  part  of  the  review  and  addressed  within  the  first  tranche  of  sites  reviewed 
during this financial year. 

Preliminary investigations have begun to develop further overtaking opportunities & safety 
improvements along the length of the A40. This includes improvements at Redstone Cross. 

These additional A40 improvements are included in the update of the National Transport 
Finance Plan (NTFP) (Page 17 ref ‘NEW2’). 
https://beta.gov.wales/sites/default/files/publications/2017-12/national-transport-finance-
plan-2017-update.pdf 

Bae Caerdydd • Cardiff Bay 
Caerdydd • Cardiff 
CF99 1NA 

Canolfan Cyswllt Cyntaf / First Point of Contact Centre:  
0300 0604400 
Gohebiaeth.Ken.Skates@llyw.cymru 
Correspondence.Ken.Skates@gov.wales 

Rydym yn croesawu derbyn gohebiaeth yn Gymraeg.  Byddwn yn ateb gohebiaeth a dderbynnir yn Gymraeg yn Gymraeg ac ni fydd 
gohebu yn Gymraeg yn arwain at oedi.  

We welcome receiving correspondence in Welsh.  Any correspondence received in Welsh will be answered in Welsh and corresponding 
in Welsh will not lead to a delay in responding.   

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 We are currently looking about how these improvements can be packaged and when they 
can be delivered alongside other priorities in the NTFP. To date no programme has been 
established to deliver these improvements and one will be developed in due course.  

Yours sincerely, 

Ysgrifennydd y Cabinet dros yr Economi a Thrafnidiaeth  
Cabinet Secretary for Economy and Transport

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